MEDICARE: ELIZABETH PETERSEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208U00000X	Clinical Pharmacology Physician	051305104	IL

General Provider Information

NPI Number	:	1174202543
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH PETERSEN

Provider Business Mailing Address
First Line	:	1531 INSPIRATION DR APT 3017
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75207-3767
Country	:	US
Telephone Number	:	720-985-7589
Fax Number	:

Provider Business Practice Location Address
First Line	:	1969 W OGDEN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-3765
Country	:	US
Telephone Number	:	312-864-6000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2023
Last Update Date	:	07/13/2023

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